Participants Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries.

Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Ensuring good patient outcomes in hospitals is increasingly challenging as national economic concerns, austerity spending and health system reforms converge to create hard choices in resource allocation.1–3 At its core, hospital care is labour intensive.

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Yet the notion persists in policy and management discussions that hospitals should be able to transition to a lower complement of high skilled workers like professional nurses to reduce costs following examples in other sectors of the economy.5 6 The premise is that fewer highly skilled/higher cost professional nurses supported by lower skilled and lower wage assistants would result in lower costs of care without adversely affecting patient outcomes, although evidence to support such contentions is lacking.

Political leaders in England have recently introduced a category of hospital caregiver called ‘nursing associate’, akin to the enrolled nurse position which was phased out in the 1990s.7 10 and nursing skill mix in National Health Service (NHS) hospitals already being one of the lowest in Europe.11Policy debates in Europe about hospital skill mix are happening in a context where evidence is limited and there is substantial variation in skill mix between and within countries.3 12–15 Hospital nursing skill mix varies from a high of 82% professional nurses in Germany to a low of 57% professional nurses in England and 54% in Spain.16 Variation in hospital nurse skill mix within countries is great as illustrated in NHS hospitals in England where nursing skill mix varies from a high of 79% professional nurses in some hospitals to a low of 47% in others.17The quality of evidence about the outcomes of nursing skill mix in Europe is very limited as noted in a Cochrane Collaboration systematic review.4 19 research of English hospitals 15 years ago, remaining one of the few multihospital studies of the outcomes of nursing skill mix in Europe, found that higher proportions of auxiliary nurses (nurse assistants with limited training) were associated with higher hospital mortality.

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